Authors : Mireira Jofre-Bonet, Joseph Kamara, Alice Mesnard
Site of Publication : PLOS ONE
Type of publication : Article
Date of publication : April 2023
A fundamental problem developing countries face is corruption creating barriers to development. Corruption has made healthcare particularly costly or unaffordable for most of the population, damaged patient care and demotivated healthcare workers. This has led to inefficient health systems with poor quality services, inequitable access, and inadequate funding. Sadly, in these countries, corruption often is perceived as a spillover effect of government intervention that can negatively affect the provision of health care services.
Considerable evidence supports the point that unofficial payments are deeply entrenched in markets for healthcare in developing countries. In addition, studies show that health sector corruption contributes significantly to developing countries’ poor health situation. Even though corruption is salient, estimating its overall cost in the health sector is challenging for several reasons: it is difficult to distinguish between corruption, inefficiency, and honest mistakes; record-keeping is often neglected; and the health sector has many stakeholders, enabling corruption to proliferate to various sub-sectors.
Corruption has made healthcare particularly costly or unaffordable for most of the population, damaged patient care and demotivated healthcare workers. This has led to inefficient health systems with poor quality services, inequitable access, and inadequate funding. Sadly, in these countries, corruption often is perceived as a spillover effect of government intervention that can negatively affect the provision of health care services
Health officials engage in corruption for various reasons, but key amongst them are (i) opportunities generated by monopoly in service delivery, discretion in decision making, poor accountability and transparency; (ii) a conducive environment where public service values are eroded, and corruption is perceived as a condition to success; (iii) low salaries, personal financial debts and similar pressures. Lewis describes that, in developing countries, medical staff are involved in under-the-table corruption because of the low and irregular payment of their salaries, lack of government action in the health care system, and the culture of gifts. Lastly, the presence of information asymmetry in the health system, its complexity, and the inherent uncertainty in healthcare markets favour the emergence of corruption.
Akin to many other developing countries, corruption is one of the most important factors to have hindered growth in the health sector of Sierra Leone. The corruption in Sierra Leone’s health sector ranges from demanding bribes for basic services to large-scale misuse of public goods for private gain by public officials. In the Transparency International Corruption Perceptions Index 2017, Sierra Leone scored 30 out of 100 (where 0 is considered highly corrupt and 100 the opposite), ranking 130 out of 175 countries. A local survey by the Anti-Corruption Commission (ACC) in Sierra Leone in 2010 shows that most Sierra Leoneans have experienced corruption in one way or another, with 94% classifying it as a problem. In March 2013, the ACC indicted 29 National Health Sector Support Project (NHSSP) officials at the Ministry of Health and Sanitation for various corruption offences regarding misuse of the Global Alliance for Vaccines and Immunization (GAVI) funds. The various charges amounted to $2,436,921. Pieterse and Lodge opine that corruption scandals have plagued the Free Health Care initiative in Sierra Leone. They quote an Amnesty International report of 2009 showing that, in most areas, staff would unilaterally and illegally charge fees and keep the money.
The corruption in Sierra Leone’s health sector ranges from demanding bribes for basic services to large-scale misuse of public goods for private gain by public officials. In the Transparency International Corruption Perceptions Index 2017, Sierra Leone scored 30 out of 100 (where 0 is considered highly corrupt and 100 the opposite), ranking 130 out of 175 countries
Moreover, the 2018 Afro barometer survey in Sierra Leone reveals that many Sierra Leoneans report delays and difficulties accessing care at public hospitals and clinics. About half say they pay a bribe to access it. The huge systemic corruption in Sierra Leone explains why up to a third of the money given to fight Ebola remains unaccounted for. With an adult literacy rate of 40%, many people are not empowered to stand up for their right to free healthcare and are often not even aware that the charges they are being asked to pay are unauthorized. Furthermore, there is inevitably a fear of reporting corruption as people fear being harassed or excluded on their next visit.
Several studies agree that corruption within the health sector is severe and must be addressed urgently; otherwise, the poor will continue to get poorer and have a shorter life expectancy. The effect of corruption is likely to have a greater burden on those who are impoverished and cannot afford to pay bribes or seek private alternatives. The Public Affairs Centre survey reveals that as much as 38% of total hospital expenses borne by households are in the form of bribes, and some 17% of households claim to have made unofficial payments to public hospitals. Moreover, people’s perception of corruption in the health sector strongly correlates with input overpricing and unofficial payments.
In Sierra Leone, like in many low- and middle-income countries, most of the adult population works in the informal sector, where activities are typically unrecorded and exist in the narrow space between legality and illegality. The informal sector emerges as a means to avoid taxes, environmental norms and labour laws. With only about 20% of adults having bank accounts in Sierra Leone, formal transaction costs are replaced by informal payments and bribes. Informal employment is unregistered, and workers are habitually paid lower wages and receive fewer benefits, such as social security, than those who work in formal employment.
With only about 20% of adults having bank accounts in Sierra Leone, formal transaction costs are replaced by informal payments and bribes. Informal employment is unregistered, and workers are habitually paid lower wages and receive fewer benefits, such as social security, than those who work in formal employment
However, there is not much literature on the impact of corruption on the uptake of (usually voluntary) state-subsidized or social health insurance schemes for the informal sector in low- and middle-income countries. To be meaningful, the estimation of the uptake drivers must overcome the problem of self-selection into insurance, which is not always possible and/or achieved. A review of the literature on this subject reveals that the uptake of insurance schemes is lower than expected. There is evidence that the low participation in Health Insurance Schemes (HIS) might be partly demand-driven and, therefore, could be addressed through an appropriate HIS design. However, several studies point out that low demand for HISs might be caused by the lack of credibility of public services due to corruption. The healthcare sector’s degree of corruption or, at least, the informal sector’s perception or experience of corruption is rarely captured in surveys on participation in HIS. Thus, the impact of corruption in the healthcare sector on participation and willingness to pay in HIS remains unanswered.
Looking at our results, several points warrant discussion. Firstly, it was found that being more educated is associated with a higher probability of perceiving high levels of corruption and a lower likelihood of having experienced it. Intuitively, these heads of household are more aware of the corruption in the health sector and more able to protect themselves from it. Related to this, following the news is, as expected, associated with a higher likelihood of perceiving corruption, but surprisingly it does not protect individuals from experiencing it. Moreover, being in an urban setting is associated with a lower likelihood of perceiving corruption and a higher one of experiencing it. This is somewhat surprising as one would expect that living in cities facilitates communication, making citizens more aware of corruption and protecting them from experiencing it compared to more rural, more isolated areas. In this context, an explanation could be that there is a higher level of corruption in the healthcare sector in urban areas, which is not fully perceived by urban dwellers and affects them. Thirdly, we note that those in the Quarrying sector appear less likely to have experienced and perceived high levels of corruption than those in other sectors. A potential reason is that Quarrying is the smallest informal sector, with high poverty levels and living in unplanned settlements (i.e., also termed slums). This could mean less contact with the healthcare system and, thus, a lower likelihood of perceiving and experiencing corruption. Fourth, the negative relationship between the likelihood of both corruption measures and household distance to the health centre can be explained by the fact that increased distance results in reduced contact with healthcare providers. While increasing the likelihood of having experienced corruption, receiving remittances does not have a significant association with perceiving it. Finally, as expected, bad health is significantly associated with both measures: having suffered from malaria or typhoid fever might have exposed household members to seeking healthcare more intensively, and hence increased their likelihood of perceiving and experiencing corruption.
Firstly, it was found that being more educated is associated with a higher probability of perceiving high levels of corruption and a lower likelihood of having experienced it. Intuitively, these heads of household are more aware of the corruption in the health sector and more able to protect themselves from it
Our results further show that experienced corruption is a significant barrier to participation in HIS run by public providers. Also, from the results of the WTP analysis, we conclude that, although the WTP for a publicly provided HIS is positive according to our estimates, having experienced or perceived corruption in the health care system makes households’ WTP considerably less willing to pay for a HIS publicly provided, undermining their WTP by more than 25%. We interpret these results as suggesting corruption undermines trust in public institutions, including health care providers.
There are limitations to our study: although the information on the household we control for is quite extensive, there are unobservable factors that are not captured, for instance, the frequency and intensity of healthcare use. Healthcare usage can explain both the perception and the experience of corruption and, at the same time, the preferences of individuals for certain HISs.